Advancing Quality Palliative Care for Patients with Chronic Kidney Disease in BC

Transcription

1 Advancing Quality Palliative Care for Patients with Chronic Kidney Disease in BC 2017 Canadian Hospice Palliative Care Conference Friday, September 22, 2017 Dr. Gaylene Hargrove & Helen Chiu

2 Territorial Acknowledgement We would like to acknowledge the Algonquin nation whose traditional and unceded territory we are gathered upon today.

3 Disclosure Nothing to disclose

4 Overview Patient case Chronic kidney disease: a life-limiting illness Mortality and morbidity in BC Provincial renal network in BC Where we have been in CKD care in BC o Advance care planning o Symptom assessment & management Lessons learned Summary

5 Patient case: Ernie 76 year old retired electrical engineer; married with two children Diagnosed with multiple myeloma April 2017; presented with severe anemia, pathologic vertebral compression fractures, stage 5 CKD requiring initiation of hemodialysis Chemotherapy successful, but no renal recovery, severe pain/ symptom burden despite palliative care consultant s efforts to optimize therapy Re-admission to hospital July 2017 intolerable pain, dyspnea, progressive vertebral and rib fractures Decision to stop dialysis late July, but death not imminent; patient decides to pursue MAiD Peaceful death with all family members at bedside mid-august Follow up: Thank you for being honest, for being a friend, for being you.

6 Chronic kidney disease (CKD): a life-limiting illness High mortality and morbidity in advanced stage o 5-year survival of older patients after starting dialysis is comparable to metastatic cancer Journey in transitions Prognostic uncertainty

7 Chronic kidney disease: Mortality in BC

8 Patients with end-stage kidney disease have multiple co-morbidities

9 Provincial renal network in BC Collaborations with health authority renal programs Active provincial multidisciplinary committees o Cross health authority representation o Annual work plans with clear deliverables o Research, evaluation and continuous quality improvement

10 Where we have been in CKD care in BC : Formal engagement and discussion around renal palliative and EOL care in the BC renal community : Development of guidelines and plans within health authority renal programs by an EOL working group : Publication of the End-of-Life Framework: Recommendations for a Provincial EOL Care Strategy

11 Framework for palliative approach to CKD care in BC

12 Where we have been in CKD care in BC (con t) : Development and implementation of education strategies for the four pillars of renal palliative care that make up the EOL Framework : Publication of protocols and algorithms for symptom management and launch of online training module for symptom assessment : Environmental scan to review progress for strategizing improvement in renal palliative care and develop 3-year goals and objectives going forward : Development and implementation of a set of quality metrics to aid strategic planning and continuous quality improvement efforts

13 Advance care planning (ACP) Goal: To enhance patient and family understanding of their health issues and identify their key priorities in care Led by local champions o Initial funding to develop process with multidisciplinary teams to integrate the process into existing work flow Sharing lessons learned spread in BC Provincial support: o Alignment with provincial and health authority efforts o ACP videos guide for MDs and staff to initiate the conversation with patients and their families o ACP module for process data capture

14 Advance care planning (ACP): Progress Social worker: key facilitator in ACP discussions in all health authority renal programs Timing of initiation varies 28 service units have started using the ACP module since 2015 Discussions Medical Orders Legislation Documents

15 Symptom assessment & management Goal: To relieve symptom burden that are generally under-reported in patients with kidney disease, thereby improving their quality of life Led by local champions o Initial funding to develop process with multidisciplinary teams to integrate the process into existing work flow Sharing lessons learned spread in BC Provincial support: o Symptom assessment module for process and outcome data capture o Algorithms for symptom management o Online training module and information sheet for MDs and staff o Symptom guides for patients

16 Symptom assessment & management: Progress Health authority renal program Fraser Interior Island Northern Vancouver Coastal- Providence Targeted populations HD Non-dialysis, HD, PD, HHD Non-dialysis, HD, PD, HHD Non-dialysis, HD, PD Non-dialysis, HD, PD Frequency every 6 months and posthospitalization every 3 months or as needed every 6 months at entry, posthospitalization, and as needed thereafter every 3 or 6 months Trigger for review medical reconciliation clinic visit medical reconciliation or clinic visit as deemed necessary designated rotation cycles or clinic visit Modified ESAS presented to patient by Nurse Nurse Pharm Tech, Nurse or Unit Coordinator Social Worker Nurse

17 Symptom assessment & management: Process and outcome measures

18 Lessons Learned Culture change takes time Focus on a common goal to improve care and quality of life Integration with existing workflow is key Successful implementation is contingent on engaging the multidisciplinary teams at the frontline Including voices of patients and other key stakeholders from the planning to evaluation The Committee s accomplishments to date have set the foundation for alleviating some of the challenges faced by kidney patients. We, the Committee's patients and health care professionals, are working together to deal with the important patient issues that haven t received sufficient focus in the past. Data capture enables monitoring of progress over time

19 Summary A series of provincial strategies enabled the culture change Success and progress are made possible with provincial renal network and champions in ACP and palliative care Collaborations across modalities and sub-specialities are possible and mutually beneficial Collaborations across CKD modalities can be challenging but integral to the culture change and equitable access to a palliative approach in the continuum of chronic care

20 Thank you! BCPRA Palliative Care Committee Dr. Gaylene Hargrove Helen Chiu Website: Facebook, Twitter,